Robotic-assisted laparoscopic extended pelvic lymph node dissection for prostate cancer: surgical technique and experience with the first 99 cases.

BACKGROUND: To date, there is still a paucity of data in the literature on robotic-assisted laparoscopic extended pelvic lymph node dissection (RALEPLND) in patients with prostate cancer. OBJECTIVE: To assess the technical feasibility of RALEPLND and to present our surgical technique. DESIGN, SETTING, AND PARTICIPANTS: From April 2006 to March 2008, we performed RALEPLND in 99 patients prior to robotic-assisted laparoscopic radical prostatectomy. Indications for RALEPLND were a prostate-specific antigen (PSA) > or = 10 ng/ml or a preoperative Gleason score > or = 7. The data were evaluated retrospectively. SURGICAL PROCEDURE: The transperitoneal approach was used in all cases. In order to gain optimal access to the common iliac bifurcation, the five trocars were placed in a more cephalad position than in patients undergoing radical prostatectomy without RALEPLND. After identification of important landmarks, the lymphatics covering the external iliac vein, the obturator lymphatic packet, and the lymphatics overlying the internal iliac artery were removed on both sides. MEASUREMENTS: The total lymph node yield, the frequency of lymph node metastases, and the complication rate. RESULTS AND LIMITATIONS: The median patient age was 64 yr (range: 45-78). The median preoperative PSA level was 7.7 ng/ml (range: 1.5-84.6). The median number of lymph nodes harvested was 19 (range: 8-53). In 16 patients (16%), we found lymph node metastasis. Complications occurred in seven patients (7%). CONCLUSIONS: RALEPLND is feasible, and its lymph node yield is well in the range of open series. The robotic-assisted laparoscopic approach in itself does not seem to limit a surgeon's ability to perform a complete extended pelvic lymph node dissection.

Laser fibre deterioration and loss of power output during photo-selective 80-w potassium-titanyl-phosphate laser vaporisation of the prostate.

BACKGROUND: The potassium-titanyl-phosphate (KTP) laser technique for photo-selective vaporisation of the prostate (PVP) has been regularly improved over the last decade. Nonetheless, decreasing efficiency of tissue vaporisation during the course of the operation and macroscopic alterations of the laser fibre's tip are regularly observed and seem to affect the outcome of this procedure. OBJECTIVE: To investigate the course of power output and to determine the type and extent of fibre deterioration during PVP. DESIGN, SETTING, AND PARTICIPANTS: Forty laser fibres were investigated during PVP in 35 consecutive patients with prostatic bladder outflow obstruction between January 2007 and August 2007 in a university hospital. INTERVENTION: All patients underwent PVP performed by three different surgeons using the 80-W KTP laser. MEASUREMENTS: Power output was measured at the beginning and regularly throughout PVP and throughout in vitro vaporisation without fibre-tissue contact. Microscopic documentation of the fibre tip was performed after the procedure. RESULTS AND LIMITATIONS: Carbonisation and melting of the fibre tip was regularly visible and appeared to be more pronounced as more energy was applied. Additionally, 90% of the fibres showed a significant decrease of power output during PVP, resulting in an end-of-lifespan (ie, 275-kilojoule) median power output of 20% of the initial value. Final median power output after in vitro vaporisation was 83% of the starting value. The extent of the structural and functional changes might only be valid for the operative technique performed in this investigation. CONCLUSIONS: Fibre deterioration caused significant reduction of power output during PVP. This finding is an explanation for the often observed decreasing efficiency of tissue ablation and may also be responsible for some of the typical drawbacks and complications of PVP. Hence, improvements in fibre quality are necessary to advance the efficiency of this technique.

Local anesthesia for transurethral manipulations: is a transrectal periprostatic nerve block effective?

Periprostatic nerve block has been reported to be an effective form of anesthesia for prostatic surgery. Recent studies have shown the simplicity and the efficacy of a transrectal approach for periprostatic nerve block. The goal of our study was to evaluate the effect of a transrectal periprostatic nerve block on the discomfort associated with rigid cystoscopy. A total of 73 patients underwent cystoscopy. Group 1 (n = 39) received a transrectal periprostatic lidocaine infiltration prior to the cystoscopy. Group 2 (n = 34) underwent cystoscopy alone. The pain that patients experienced during cystoscopy was assessed on a visual analog scale. The patients in the two groups were very similar in regard to age and size of the prostate. The mean pain score was 3.4 in group 1 and 3.9 in group 2. This difference was not statistically significant. We conclude that nerve block does not seem to reduce the pain associated with transurethral manipulations.

A new high frequency electrostimulation device to treat chronic prostatitis.

PURPOSE: We prospectively observed a possible benefit from urethro-anal high frequency electrostimulation in patients with noninflammatory chronic pelvic pain syndrome (Cat IIIB CPPS) as a new treatment option. MATERIALS AND METHODS: A total of 88 patients with a referral diagnosis of chronic prostatitis underwent fractionated urinary cultures, including expressed prostate secretion and ejaculate analysis twice. Of this group 14 men with Cat IIIB CPPS elected electrostimulation. A urethro-anal stimulation device was applied twice weekly for 30 minutes during 5 weeks at a defined voltage of 6 V, a defined frequency of between 450 and 500 Hz, and a variable self-regulated current of between 1 and 10 mA. National Institutes of Health prostatitis symptom score and quality of life index were determined before and after the treatment. RESULTS: All patients tolerated stimulation and completed the treatment course. No urethral or anal complications occurred. Generally, the patients reported a distinct perineal feeling and the pain syndrome improved in 83%. The mean total National Institutes of Health prostatitis symptom score significantly decreased from 29 (range 20 to 37) to 14 (range 8 to 24) points (p = 0.002). Mean pain decreased from 15 (range 12 to 20) to 7 (range 4 to 13) points (p = 0.002). Micturition complaints decreased from 2.5 (range 0 to 9) to 1 (range 0 to 8) points (p = 0.007) and quality of life improved from 9.5 (range 8 to 12) to 5.5 (range 3 to 10) (p = 0.003). CONCLUSIONS: To date the new high frequency urethro-anal afferent electrostimulation device seems to have an important benefit in patients with Cat IIIB CPPS. The device is technically simple and it can be self-administered. Therefore, it may become a new ambulatory treatment option for patients with chronic pelvic pain syndrome.